Category Archives: toilet training

A Fun Way to Help Kids With Low Tone Stand Up Straight: Stomp-Stomp!

sven-brandsma-gn-I07tTixw-unsplashKids with hypermobility or low tone are often found standing in the most dysfunctional of positions.  Toes pointing in, feet rolled in or out, feet on top of each other: take your pick, because these kids will alternate between these wobbly choices and more!  Read How To Improve Posture In Children With Low Muscle Tone… Without a Fight! and How To Correctly Reposition Your Child’s Legs When They “W-Sit” for some other ideas.  But if you want a quick idea that works to help a child stand up with better control and stability, read on.

Telling a child to “fix your feet” often makes no sense to them, or gets ignored.  Passively repositioning their feet doesn’t teach them anything, and can annoy children who feel that they are being manhandled.

What Can You Do?

Tell Them To “Stomp-Stomp”!

Have the child stomp their feet. Repeat if necessary (or because they want to).   It is simple, you can demonstrate it easily, and most kids grin happily and eagerly copy you.  It is fun to stomp your feet.  It also give kids a chance to move in place, which they often need when socially distancing in a classroom.

 

Why Does It Work?

Because in order to stomp their feet, they have to bring their attention to their feet, shift their weight from one foot to the other in order to lift them up, and their feet almost always end up placed in a more aligned position after stomping.

Many of the goal boxes their PT and your OT have on their list are checked.  Kids don’t feel controlled or criticized.  They are having fun.  Sensory input happens in a fun way, not as an exercise.

Want more help with your child, or help improving treatment plans as a therapist?

I wrote three e-books for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone, and the JointSmart Child series on hypermobility are all valuable resources for parents and therapists.  I wrote them because there is simply nothing out there that provides an explanation for why these symptoms make life so difficult for kids (and parents, and teachers, and even therapists!) and what can be done to make everyday life better.

Learn why low tone and hypermobility both create sensory processing issues, and what kinds of social and emotional issues are understood to accompany hypotonia and hypermobility.  When parents see these issues as complex rather than only about strength and stability, they start to feel more empowered and more positive.

Read more about these books, available for purchase on Amazon and Your Therapy Source,  in A Practical Guide to Helping the Hypermobile School-Age Child Succeed, and The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! as well as The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Toilet Training? Your Child Needs the Right Shorts!

 

In my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I wrote almost a full chapter just on clothing management.  If your child needs you to pull clothing on and off, they are NOT fully trained.  And if they have clothes that make it impossible for them to manage, you are holding them back from feeling like a real success.

Target has your back!

Yes, the same place you go for their swimsuits, toilet paper, and hand soap.  Target sells a cheap pair of shorts that children can easily pull down and back up again.  Their Cat and Jack line is pretty inexpensive, which is helpful when you know that you will be going through a few pair of shorts per day due to accidents.  They are soft to the touch for kids with sensory sensitivities, and they do have a drawstring waist if you have one of those kids whose shorts slide off their tush.  But remember that if you knot it, your kid won’t be able to slide their shorts off easily.  Better to buy a smaller size.

I would pair these with a T-shirt that ends close to their natural waist.  A longer top will get in the way during bathroom use.  You want to give your child every chance to have a positive experience, and peeing on your clothing by accident isn’t a positive!

Here is a link to a post on dressing skills: Low Muscle Tone and Dressing: Easy Solutions to Teach Independence

Want more help with your child?  

The Practical Guide….. is available on my website Tranquil Babies as a printable download, and on Amazon as a read-only download.  It is also available on Your Therapy Source individually and bundled with either my book on hypermobility in very young children The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! or as a discounted super-bundle with my book on hypermobility in school-age children included A Practical Guide to Helping the Hypermobile School-Age Child Succeed

Is Your Child With Low Tone “Too Busy” to Make it to the Potty?

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Since writing my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I have fielded a ton of questions about the later stages of potty training.  One stumbling block for most children appears to be “potty fatigue”.  They lose the early excitement of mastery, and they get wrapped up in whatever they are doing.  What happens when you combine the effects of low tone with the inability of a  young child to judge the consequences of delaying a bathroom run?  This can lead to delaying a visit to the bathroom until it is too late.  Oops.

Kids with low tone often have poor interoceptive processing.  What is that?  Well, interoception is how you perceive internal sensory information.  When it comes to toileting, you feel fullness in your bladder that presses on your abdominal wall, in the same way you feel a full stomach.  This is how any of us know that we have to “go”.  If you wait too long, pressure turns to a bit of pain.  Low muscle tone creates a situation in which the stretch receptors in the abdominal muscles and in the bladder wall itself don’t get triggered until there is a stronger stimulus.  There may be some difficulty in locating the source of pressure as coming from the bladder instead of bowel, or even feeling like it could be coming from their back or stomach.  This leads to bathroom accidents if the toilet is too far away,  if they can’t walk fast enough, or if they cannot pull down their pants fast enough.  You have to work on all those skills!

Add in a child’s unwillingness to recognize the importance of the weak sensory signals that he or she is receiving because they are having too much fun or are waiting for a turn in a game or on a swing.  Uh-oh.  Not being able to connect the dots is common in young children.  That is why we don’t let them cross a busy street alone until they are well over 3 or 4.  They are terrible at judging risk.  Again, this means there are skills to develop to avoid accidents.

What should parents do to help their children limit accidents arising from being “too busy to pee?”

  1. Involve kids in the process of planning and deciding.  A child that is brought to the potty without any explanations such as “I can see you wiggling and crossing your legs.  That tells me that you are ready to pee” isn’t being taught how to recognize more of their own signs of needing the potty.
  2. Allow kids to experience the consequences of poor choices.  If they refused to use the potty and had an accident, they can end up in the tub to wash up, put their wet clothes in the washer, and if they were watching a show, it is now over.  They don’t get to keep watching TV while an adult wipes them, changes them, and cleans up the mess!
  3. Create good routines.  Early.  Just as your mom insisted that you use the bathroom before leaving the house, kids with low tone need to understand that for them, there is a cost to overstretching their bladder by “holding it”  Read  Teach Kids With Ehlers-Danlos Syndrome Or Low Tone: Don’t Hold It In! to learn more about this.  The best strategy is to encourage a child to urinate before their bladder is too full, make potty routines a habit very early in life, and to develop the skills of patience stretching Stretch Your Toddler’s Patience, Starting Today!  from an early age.  Creating more patience in young children allows them to think clearly and plan better, within their expected cognitive level.

Looking for more information on managing daily life with your special needs child?

I wrote three e-books for you!

My e-book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, and my e-books on managing pediatric hypermobility, are available on Amazon as read-only downloads, and on Your Therapy Source as printable downloads.  The JointSmart Child:  Living and Thriving With Hypermobility  Volume   One:  The Early Years and Volume Two:  The School Years are filled with strategies that parents and therapists can use immediately to improve a child’s independence and safety.

Your Therapy Source has bundled my books together for a great value.  On their site, you can buy both the toilet training and the Early Years books together, or buy both hypermobility books together at a significant discount!

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Potty Training in the COVID-19 Age

 

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Parents are staying home with their toddlers and preschoolers now.  All day.  While this can be a challenge, it can also be the right time to do potty training.

Here’s how to make it work when you want to teach your toddler how to “make” in the potty:

  1. You don’t have to wait for readiness.  What you might get instead is a child that has lost the excitement of being praised by adults, and fears failure more than seeks praise or rewards.  If that sounds like your child,  quickly read Waiting for Toilet Training Readiness? Create It Instead!
  2. Have good equipment.  If you don’t have a potty seat that fits your child or a toilet insert and a footstool that is stable and safe, now is the time to go online shopping for one.  Without good equipment, you are already in trouble.  Children should be able to get on and off easily and not be fearful of falling off the toilet.  If you are training a preschooler and not a toddler, you really need good equipment.  They are bigger and move faster.  Safety and confidence go hand in hand.
  3. Have a plan for praise and rewards.  Not every child will want a tiny candy, but nobody should expect a new toy for every time they pee in the potty.  Know your kid and know what gets them to try a new skill.  Some children don’t do well with effusive praise Sensitive Child? Be Careful How You Deliver Praise , so don’t go over the top if this is your kid.
  4. Know how to set things up for success.  If your child is typically-developing, get Oh Crap Potty Training by Jamie Glowacki, because she is the best person to tell you how to help you be successful.  She even has a chapter just on poop!  If your child has hypotonia or hypermobility, consider my e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone.  It is inexpensive, available on Amazon and Your Therapy Source, and gives you checklists and explanations for why you need to think out-of-the-box to potty train these kids.  You don’t leave for vacation without a map.  Don’t wing this.  Just don’t.
  5. Build your ability to calm yourself first.  Exactly like on an airplane, (remember them?  We will get back on them eventually) you need to calm yourself down in the face of refusals, accidents and tantrums.  You are no good to anyone if you are upset.  Read Stress Relief in the Time of Coronavirus: Enter Quickshifts and Should the PARENTS of Kids With Sensory Issues Use Quickshifts? for some ideas.

Looking for more information on potty training?  I wrote an e-book for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone was my first e-book.  It is still my best seller.  There is a reason:  it helps parents and kids succeed.  This unique book explains why learning this skill is so tricky, and it gives parents and therapists detailed strategies to set kids (and parents) up for success!  Understanding that the sensory and social-emotional impacts of low muscle tone are contributing to potty training deals is crucial to making this skill easier to learn.  I include a readiness guide, strategies to pick the best equipment and clothes (yes, you can dress them so that they struggle more!), and how to move from the potty seat onto the adult toilet.

It is available on Amazon and on Your Therapy Source, a great site for materials for therapists as well as parents looking for homeschooling ideas.

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Does Your Toddler Resist Diaper Changes? End The Drama Today!

 

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does this look familiar? read on!

I regularly field questions about this problem from the parents of children I treat.   If your 8 to 24-month old is fussy during diaper changes and you know it isn’t from diaper rash, keep reading.  I have some information and ideas for you.

Parents of kids with sensory processing issues or developmental delays often assume that this is the source of their child’s diaper drama.  Parents who lack confidence or parents who spend a lot of time online with “Dr. Google” think that it could be sign of autism or of poor attachment.

Nope.

At least, not usually.

If your young child is suddenly giving you the business, even though they really need a diaper change, there are a few things to think about before you run to a developmental pediatrician (or any pediatrician):

  1. Your child may have been busy exploring, and they are unhappy that they were interrupted with a task they find boring.  Getting a fresh diaper isn’t much fun after those first few months of face-gazing and smiles.  Once a child can really play, they have better things to do.   Parents can be surprised that their gurgling infant that loved diaper changes is now resisting, or even fighting, to get off the changing table.
  2. If your child is one of the 15-20% of kids that Dr. Harvey Karp identifies as having a “spirited” temperament, then you are going to get a strong reaction to  almost any action they didn’t initiate.  Bedtimes, leaving to go to the park, leaving the park to go home, etc.  Spirited kids are going to give you oversized reactions in both directions; super happy, super sad, super angry.
  3. Kids with limited receptive language aren’t sure exactly what is going on when you pick them up.  Receptive language means understanding the words another person is using.  Your child doesn’t have to be delayed; they could simply not have enough language skills to understand what you are saying.
  4. Your child has decided to use diapering as their “line in the sand” to express their independence and test your limits.  Testing limits is normal, and I believe that nature intended this to start early.   By the time parents are experiencing limit testing with a teen, they have been practicing for a while.  Young children that feel that they are being controlled will test more and with more energy.  This doesn’t mean that their parents are actually more controlling.  Perception is reality, and if a child feels micro-managed, then they react whether or not they are indeed highly controlled.  This could happen when they spend a lot of time with babysitters instead of parents, or if they have had many recent changes in caregivers, new sibling, new home, etc.

What works to reduce diaper drama?

  • Use routines to improve language comprehension and manage expectations.  Kids that get a regular diaper check/change know what you are doing and where they are going.
  • Shorten your phrases and use the same words for the same events.  See above.
  • Try not to over-react to an overreaction.  Spirited kids don’t need more fuel for the fire, and neither do tired, sick, or hungry children.
  • Give your child more chances to control other situations in their life.  Manufacture the situations if you have to.  This means that they get to decide of the doll goes in the cradle or the car, or if the blue car goes down the ramp first, or if it is the red car that leads.  Dr. Karp’s “give it in fantasy” strategies  Give (Some of) Your Power Away To Your Defiant Toddler And Create Calmness and all of his positive “time-ins” are excellent ideas to build a child’s sense of fairness and autonomy.
  • Offer the 8-24 month old child something interesting to hold and look at during the diaper change.  It could be a new soft toy, but it might be better to give them a tiny collapsible colander to examine.  The novelty factor should buy you enough time to do the deed.  Remember to change it up regularly.  They need to learn to expect that this could be more fun than drama.
  • Older kids with the language skills to understand the negotiation could be asked “Do you want your diaper change NOW or in one minute?”  It doesn’t have to be 60 seconds later.  The idea is that you have given them a choice.  You have to stick to the agreement.  If they still balk after the minute is up, don’t use this again right away.  You will be teaching them that their protests work to avoid following your directions.  Oops.

The truth is that most children know that you are going to change their diaper regardless of their protests, and they can handle it if you help them a little bit.

 

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Targeted Toilet Training Strategies to Help The Child With A Receptive Language Delay

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After writing my first e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! ,I continue to think of additional issues that can complicate (but not derail)  training.  One of these issues is a receptive language delay.  This is when a child’s ability to comprehend language is not age appropriate.  It may be accompanied by a delay in expressive language as well.  I don’t think it is a hard stop to training, but there are some strategies that improve the experience.  Not all of them are obvious.

When a child is unable to easily and quickly understand what you are saying during toilet training, you will need to do a few things differently:

  1. Expect to need established routines to support your verbal instruction.  This can include very regular trips to the potty rather than happening randomly.  Routines are essential for all children, but these kids really need them to shore up the language you are using.  Think about buying something in another language.  The routine or presenting the item, finding out the fee, offering payment and leaving with your item helps you get over the fact that you have forgotten most of your high school level French.  When they always sit on the potty right before a specific show, they know why and what you are saying more easily because they know the context.
  2. Use clear and consistent gestures and facial expressions as additional messaging while teaching and encouraging performance.  Gestures and facial expressions clarify your words and help kids respond quickly.  If they have too many accidents because they were confused, they could decide to stop cooperating.
  3. Monitor your language complexity, and consider simplifying it for ease of comprehension under stress.  As in the Fast Food Rule’s use of Toddler-ese, shorten phrases and emphasize important words.  This is not the time to lengthen your statements.  Repeat if necessary, but don’t elaborate.  Read Taming Toddler Tantrums Using Sympathetic Reframing for more details on TFFR.
  4. Assume that you will need to be more enthusiastic, more positive, and spend more time on training in general.  Your child is probably already someone with a short fuse.  Struggling to understand what people are saying makes that easy.  Now you are trying to teach a new skill, possibly one that they aren’t 100% excited to learn.  That doesn’t mean never teach it.  It means have a good plan, with lots of optimism and patience on your part.

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Afraid to Toilet Train? Prepare Your Child… and Prepare Yourself

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I spend an extra 30 minutes at the end of a session this week helping a mom build her courage and confidence so that she felt ready to start toilet training soon.  Her child is over 3, has sensory and motor issues, but shows tons of signs for readiness:  dry diapers for increasingly long periods, tells adults when he needs to “go”, able to manage clothing, etc.  He also has no confidence in his abilities, rarely likes change or challenge, and is super-sensitive to altering routines and using new environments.  This isn’t going to be seamless.

It isn’t clear who is the more prepared individual, but I think it could be the child.

This mom read my favorite marketplace book on training “Oh Crap”, and she needs to re-read it with an eye to the many ways in which her child fits the picture of a child that could NEVER be fully ready to train.  This species is so averse to novelty and challenge that no treat or toy is a great enough reward.  Nothing is more frightening to them than failure, and you simply cannot miss the diaper.  It is familiar, fail-proof, and allows children to never have to monitor their body signals or stop watching Paw Patrol to go to the potty.  Ever.

This child is likely to be experiencing the normal sensations of fullness and pressure (as the bladder and rectum fill) as uncomfortable and a little scary.  This interoceptive input can be one that children are sensitive to in the same way that the find seams on clothes or lying down for a diaper change unpleasant.  He requires a lot of support to tolerate and process tactile input and vestibular input, so it isn’t exactly surprising that he would find interoceptive sensation difficult to handle.  Adding a new routine for dealing with elimination, placing it in a room he rarely uses (the bathroom) and being old enough to know that he could “fail” and old enough to absorb outside comments about being “dirty” is more than enough to make this harder than it should be.

My suggestions to this mom included:

  • Adding more vocabulary to her discussions about toilet training.  Speaking about the feelings of pressure and fullness, the actions of pushing the poop out gently, and cleaning/wiping with clear messaging that this is a learning experience that nobody does perfectly.  Hearing that his parents had “accidents” when they were little, and that every child will have accidents, well, this could really help both of them.
  • Dressing him lightly, or choosing to go naked or just underpants (I like two layers of training pants if they still fit his tiny heine!) so that there are fewer barriers to making it to the potty means she may need to shop for training garments.
  • Planning the environment if she is going to let him go naked.  All living events except sleeping need to happen in places where accidents can be cleaned up easily.  She isn’t averse to staining the carpet, but I assured her that her child knows not to spill things on that carpet.  He is too old not to interpret soiling it as a failure.  When she runs to clean it up, he will feel badly.  If she doesn’t have to rush and shows no stress, he will relax about the almost inevitable accident.  He NEEDS  the confidence to move forward.
  • Consider more media about toileting and the arc of learning.  Most children don’t like to talk about things that distress them.  But they LOVE to read about others who are going through the same things.  I suggested that she weave in some new books about characters who are learning to use the toilet, and add comments about their feelings as they learn.  This would include how excited and proud the character is.  Proud can be a new word in his vocabulary!

 

Training a child that has low tone?  I wrote an e-book for you!

The Practical Guide to Toilet Training Your Child With Low Muscle Tone is filled with preparation ideas, strategies to address the common issues of sensory processing limitations and the behavioral effects of low tone, and even includes a guide to building readiness instead of waiting for it to arrive!  You can find it on my website Tranquil Babies,  on Amazon  , and on a terrific site for occupational therapy materials, Your Therapy Source

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Should You Install a Child-Sized Potty for Your Special Needs Child?

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Affordable accessibility and no institutional appearance!

I know that some of you don’t even realize that such a thing exists:  a toilet sized for preschoolers and kindergarteners!  Well, you won’t find it in Lowe’s or Home Depot on the showroom floor, but you can buy them online, and it is an option to consider.  Here are the reasons you might put one in your child’s main bathroom:

  1. You have the space already.  Some homes are large enough to allow each bedroom to have its own bathroom.   If you have the option, it might be worth it during renovations.  It shouldn’t add considerably to the overall cost, and it should not be that difficult to swap out when your child grows.  If you have a bathroom near the playroom, that might be another good location for this potty.  Most older kids and adults can make it to another half-bath on that floor, but it might be perfect for your younger child and his friends!
  2. Your child is terrified of the standard-height potty.  Some kids are unstable, some are afraid of heights, and some have such poor proprioception and/or visual skills that they really, really need their feet on the ground, not on a footstool.
  3. Your child was a preemie, and their growth pattern indicates that they will fit on this toilet comfortably for a while.  Some preemies catch up, and some stay on the petite size.  Those children will be able to use a preschool-right potty into early elementary school.  Even if your preemie is average in size, they may have issues such as vision or sensory sensitivity that will make this potty a great idea for a shorter time.

I am just beginning to build my materials to do in-home consultations as a CAPS, but I think that an underserved population are parents of special needs kids that would benefit from universal design and adaptive design.  This toilet would come under the category of adaptive design, and it is an easily affordable solution for some children.  Having more comfort on the toilet speeds up training for many kids.  It also decreases the aggravation of training and monitoring safety for parents.  I am very committed to helping the entire family have an easier time of things like toilet training.

Think about what your family’s needs and capabilities are, and if you are planning to remodel or build a new home, consider finding a CAPS professional in your area to help you make your home as welcoming for your special needs child as possible!  For more information, read How An Aging-In-Place Specialist Can Help You Design an Accessible Home for Your Child.

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How Being Toilet Trained Changes Your Child’s Life

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Think your child doesn’t care that he is wearing pull-ups in pre-K?  Well, he might not…yet.  After all, he doesn’t know another life.  He has been using a diaper (because we know that pull-ups aren’t anything other than a diaper, right?) for elimination since his first day of life.  Wait until he is trained, and you may see the difference that being trained will make for him.

Children who have accomplished toilet training have made a significant step forward in independence.  They are the masters of their domain, to borrow from Seinfeld.  Not needing help for something so personal, they have a different attitude about body ownership and privacy.  This is important and personally meaningful.  We want children to have pride in their bodies and a sense that they own them.  Even though you would never harm your child, when you are involved in their “business”, you are taking some of that pure ownership away.  The sooner they have a sense that they can manage alone, or with only a bit of help for the hard bits, they build their sense of self.

When kids master a major life skill, they often are more willing to take on other skills such as writing and dressing.  They are interested in holding their spoon and fork the “grown-up” way.  They have entered the world of the older child, in their minds.  And adults aren’t immune.  We see potty trained kids differently too.  When they are able to take care of themselves in the bathroom, we start raising our expectations for them as well, and treat them as older children, not babies.  And they react to our change in perception as well.  Toilet training can lift everyone up!

The practical realities of life mean that being trained allows them to go to activities and even schools that they wouldn’t be able to attend.  Pools and camps have rules, and being fully engaged with their community means being out there and participating as much as possible.

A mom told me yesterday that her 5 year-old told her “I am so happy that I can use the potty!”  It took him a long time to get all the skills together to be fully trained, and he is off on a family cruise next week.  This will be the first time he can attend cruise camp with his older brother.  He has arrived!

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Could Your Pediatric Client Have a Heritable Disorder of Connective Tissue?

 

vincent-van-zalinge-752646-unsplashTherapists see lots of hypermobile kids in clinics and schools.  I see hypermobile children  every week in their homes for private sessions, consultations and ongoing treatment through Early Intervention.  My estimate is that at least 25% of kids over 5 and almost 50% of the younger kids I have treated have some degree of hypermobility.  But young children are naturally more flexible than older kids, and there are other diagnoses that include hypermobility.  What would cause  a therapist to suspect a rare CTD when so many children have this one symptom?

You observe the systemic signs and symptoms that could indicate an HDCT, and you ask their parent(s) for details about their health and activities.  You will need far more information than you can get from your intake evaluation to explore the possibility of a heritable disorder of connective tissue.

Here are a few of the more common current or past indicators of a HDCT:

  • Multiple joint involvement.  Not just lax hands, but laxity at many joints, both small and large at times.
  • Skin that is either very smooth, very thin, or bruises easily, and bruises in places that are not common sites for active children.  For example, shins and dorsal forearms are commonly bruised in play.  The medial aspect of the thigh and the volar forearm, not so much.  It is not uncommon for ER staff to incorrectly suspect abuse when they see this pattern, so be aware that as a mandated reporter, you have to ask more questions before you make that call.
  • Sensory processing issues that are primarily poor proprioception, sensory seeking and perhaps poor vestibular functioning.  Children with a HDCT may have no sensory sensitivity and no modulation issues, and good multi-sensory processing.  Why good?  The more information they receive, the less the impact of poor proprioceptive input makes on performance.  With good positioning and support, their sensory issues seem to significantly disappear or are eliminated Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior.
  • Lower GI issues or incontinence issues.  These kids may have more toilet training problems and more issues with digestion than your micro-preemies at ages 4 or 5.  Girls may have a history of UTIs, and both genders can take a long time to be continent all night Teach Kids With EDS Or Low Tone: Don’t Hold It In! You may hear about slow GI motility or a lot of sensitivity to foods that are not common allergens in children.
  • Dental issues such as bleeding gums or weak enamel.  Remember, if it is a CTD, then there will be problems with many kinds of tissue, not just skin or tendons.  Read Hypermobile Child? Simple Dental Moves That Make a Real Difference in Your Child’s Health for more practical ideas.
  • Strabismus or amblyopia are more commonly seen in HDCT.
  • Really slow progress in therapy, even with great carryover and a solid team.
  • Recurrent injuries from low-impact activities that were well-tolerated the day before.   Micro-trauma can take a day to develop into pain, swelling or stiffness.  You  could see overuse trauma that doesn’t make sense at first, because the overuse is just regular levels of activity but for a CTD, this IS overuse.

Should you say something to a parent?  I don’t have a license to diagnose children, but I may contact their referring physician if I see many indications that a child needs more evaluation.  More directly, I can help parents manage the issues that fall within my practice area, and educate families about good joint protection, equipment choices, and body mechanics.

 If a child does have a HDCT diagnosis,  the current and future risks of certain sports and careers should be discussed with families.  As therapists, we know that early damage can contribute to significant impairment in decades to follow.  Just because a child isn’t experiencing severe pain now isn’t an indication of the safety of an activity.  Understanding the many ways to adapt and adjust to ensure maximal function and maximal preservation of function is embedded in every OT.  Adapt your treatment protocols to respect the nature of a CTD, such as in  Can You K-Tape Kids With Ehlers-Danlos and Other Connective Tissue Disorders?

We can make a difference for these kids and their families, but only if we know what we are really treating.

Are you a therapist looking for clinical guidance?  Visit my website tranquil babies and connect with me through a phone or video session.  With over 25 years of pediatric experience, I have probably tried all of the techniques you are considering, and treated children with the diagnoses that keep you guessing.  Make your treatment sessions more productive, and your treatment day easier, with some professional coaching today!

Are you a parent of a child with a CTD?  Or an adult with a CTD?  A coaching phone/video session may answer your questions about diagnosis and treatment, and help you craft a more successful home program.  This is not the same as a treatment session, but especially if you are getting private therapy services, you want to be an informed consumer and get targeted help from your healthcare providers.  Coaching can help you be that effective parent or patient.  Visit my website tranquil babies and get started today!

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Three Reasons Why Your Constipated Toddler May Also Have Bladder Accidents

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Kids with chronic constipation are a challenge to train.  It can often appear that withholding is the issue, and to be certain, fear and pain are real issues.  But there are some physiological problems caused by constipation that contribute to bladder problems, and they aren’t always what your pediatrician is thinking about.

  1. The constant fullness of the colon can lead to bladder misplacement.  The bladder can be compressed and even folded, depending on exactly where the blockages exist.  This is not good for any organ, but it is especially a problem for a hollow organ that should be filling and emptying regularly.   The sensation of fullness with a misplaced bladder is therefore corrupted, so the child is not receiving correct input.  They may feel that they “have to go”, only to have nothing in their bladder, or very little.  They may fill up really fast and have to run to the toilet before they have an accident.  Too many accidents, and a child can beg for that pull-up so that they aren’t embarrassed or inconvenienced.  Even the little ones are subject to shame that isn’t from you as a parent, but in comparison to older kids or sibling comments.
  2. Chronic constipation stretches the pelvic floor, and therefore there is both less stability and less control.  The pelvic floor muscles help us to hold the urine into the bladder in time to get to the toilet, in conjunction with the sphincters.  Poor control and poor awareness go hand-in-hand.  There are physical therapists that specialize in pelvic floor rehab, but this isn’t easy to do with children that have limited language.  Not impossible, but not easy.  Letting the problem go until they are older means risking years of psychological and physical stress.
  3. Withholding due to pain or fear is a huge issue, and it can become automatic.  This means that solving the constipation issue may not immediately result in continence.  Using a wide range of approaches, including manual therapy, behavioral strategies, medications and diet control, and even core stability and sensory processing strategies, may be needed.

My final comment is that chronic constipation is nothing to ignore.  It needs to be addressed well and early.  It often doesn’t solve itself, and it may need more than a spoonful of Metamucil to clear up.  Get help and request consultations early rather than waiting to see how things “go”!

For more information about toilet training, see For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up and The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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A Great Toilet Training Book for Neurotypical Kids: Oh Crap Potty Training!

sean-wells-471209My readers know that I wrote an e-book on potty training kids with low tone ( The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived! ) but I have to admit, I learn a lot from other authors.  Jamie Glowacki  has written a terrific book that speaks clearly and directly to parents who aren’t sure they are up to the challenge of toilet training.  Oh Crap Potty Training is a funny title, but it is filled with useful ideas that help parents understand their toddler better and understand training needs so they can tackle this major life skill with humor and love.  I have to admit, I am really happy that she suggests parents of kids with developmental issues ask their OT for advice.  So few parents actually do!

Here are a few of her concepts that illustrate why I like her book so much:

  1. She gets the situation toddlers find themselves in:  using the potty is a total change in a comforting daily routine.  Jamie points out that since birth, your child has only known elimination into a diaper.  The older they are when you start training, the longer they have been using diapers.  WE are excited to move them on, but they can be afraid to sit, afraid to fail, and afraid of the certainty of the diaper always being there.  You can’t NOT get it in the diaper!  She also gets the power struggle that can be more enticing to an emerging personality after about 30 months of age.  Just saying, she gets it.
  2. Potty training success opens meaningful doors for kids, diapers keep them back.  Some great activities and some wonderful schools demand continence to attend.  By the time your child is around 3, they can feel inferior if they aren’t trained, but not be able to tell you.  They express it with anxiety or anger.  If you interpret it as not being ready, you aren’t helping them.
  3. Some kids will NEVER be ready on their own.  I know I am going to get some pushback on this one, and she already says she gets hate mail for saying it.  But there is a small subset of kids who will need your firm and loving direction to get started.   Waiting for readiness isn’t who they are.  If you are the parent of one of these kids, you know she’s right.  Your kid hasn’t been ready for any transition or change.  You have had to help them and then they were fine.  But this is who they are, and instead of waiting until the school makes you train her or your in-laws say something critical to your child, it might be OK to make things happen rather than waiting.
  4. You must believe that you are doing the right thing by training your child.  They can smell your uncertainty, and it will sink your ship.  She really sold me on her book with this one.  As a pediatric therapist, I know that my confidence is key when instructing parents in treatment techniques for a home program.  If I don’t know that I am recommending the right strategy, I know my doubt will show and nothing will go right.

If you are looking for some ideas on training kids of all stripes and needs, check out my posts  For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up and Toilet Training For Preschool And Stuck in Neutral? Here’s Why…...  Of course, if your child has low muscle tone or hypermobility, my e-book will help you understand why things seem so much harder, and what you can do to make potty training a success!

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For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up

 

photo-1453342664588-b702c83fc822For children with either low muscle tone or spasticity, toilet training can be a real challenge.  If it isn’t clothing management or making it to the potty on time, they can have a hard time perceiving that NOW is the time to start heading to the toilet.

Why?  Often, their interoception isn’t terrific.  What is interoception?  Think of it like proprioception, but internal.  It’s the ability to identify and interpret sensory information coming from organs and internal tissues.  Among them, the pressure of a full bladder or a full colon.  If you can’t feel and interpret sensation correctly, your only clue that you need the potty is when your pants are soiled.  Uh-oh.  A child with muscle tone issues is almost certainly going to have sensory issues.  Tone will affect the amount and quality of sensory feedback from their body.

What can you do to help kids?  The simplest, and the fastest solution I have found, is to tell them to stand up and see if they have changed their mind.  Why?  Because in a sitting position, the force of a full bladder or colon on the abdominal wall and the pelvic floor isn’t as intense.  Gravity and intra-abdominal pressure increase those sensations in standing.  More sensation can lead to more awareness.

So the next time your child tells you they don’t have to “go”, ask them to stand up and reconsider their opinion.  Now, if they are trying to watch a show or play a game, you aren’t going to get very far.  So make sure that they don’t have any competition for their attention!

Looking for more information on toilet training?  Well, I wrote the (e) book!  The Practical Guide To Toilet Training Your Child With Low Muscle Tone gives you readiness checklists and ways to make readiness actually happen.  It has strategies you can use today to start making progress, regardless of your child’s level of communication and mobility.  Learn what occupational therapists know about how to teach this essential skill!  It is available on my website tranquil babies, on Amazon and on a terrific site for therapists and parents Your Therapy Source.  Read more about my unique book:The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Universal Design For Parents of Special Needs Kids: It’s Important for You Too!

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Stunning, but how many potential safety problems can YOU spot?

I just finished the coursework for my CAPS certification (certified aging-in-place specialist)!  Amazing instructor and loads of valuable information about construction and renovation that only the National Association of Home Builders could impart.   And not just for aging-in-place; the concepts of accessibility make homes more visitable for family and friends, and more livable and adaptable for the future.   Now I have to decide how to add this knowledge to my practice to help families make their lives easier and better….might as well start blogging about it now!

Universal design is more visible in public places.  Hotels are installing features that make showers more accessible and banks are providing variable-height counters to fill out deposit slips.   But most of us don’t think that we need universal or accessible design in our own homes as non-disabled adults.  Wrong.

Universal design allows your great-grandmother more ease when she wants to meet your baby in your own home.  It helps your neighbor with multiple sclerosis come over and water your plants when you take the kids to Disney.  And it allows you to carry a kid, carry a bag and pull the dog into the house without dropping one of them.  Universal design also allows your husband, who tore his achilles tendon during a pickup basketball game, to get into the shower by himself while he decides if he can admit he’s not 25 anymore.

 But for parents of kids with special needs, the need is two-fold: universal design helps them do a demanding physical job, but it also allows their children more independence earlier. These parents are lifting and carrying heavier children than they might otherwise.  In and out of the car, the crib, the stroller and more.  There is a big difference between lifting a 20-pound toddler and a 47-pound preschool child wearing heavy AFOs.  Parents are hauling around equipment like therapeutic strollers, standers and medical equipment every day.  I have written a bit about positioning your child How To Get Your Special Needs Child To Sit Safely In The Tub and Kids With Low Muscle Tone: The Hidden Problems With Strollers  and Should You Install a Child-Sized Potty for Your Special Needs Child?, but now I will be addressing design beyond equipment.

Universal design’s principles of low physical effort and adequate size/space for approach and use will give enough room at a landing for the stroller, and the parent, and the dog.  It will make it possible for your child to open the door for himself and to reach the sink without being held up to the water.   Universal design’s principles of equitable and flexible use will allow children more access with less assistance as they build skills.  The principles of simple and intuitive use, tolerance for error and perceptible information reduces confusion and safety risk to children.  A good example would be faucets with both temperature control valves to prevent scalding and handles marked with red/blue codes instead of H/C.  No reading interpretation is required once your child knows “red is hot” or “red is stop”.  That happens easier and earlier than reading skills.

I don’t hear a lot of parents complain about the wear-and-tear on their bodies as they care for their children, but I see it.  Parents: don’t think that because you don’t say anything that your occupational therapist isn’t aware that your back is giving out.  That is a shame, because OTs could be helpful to parents in this situation.  Not in telling them to hire help, but in teaching them how to move with more ease and how to select and use equipment based on universal design principles to make life better for everyone.  Read How An Aging-In-Place Specialist Can Help You Design an Accessible Home for Your Child for more information on this subject.

Maybe after this post, I will be hearing from all those parents who go to bed tired and wondering how they will be able to keep up with the physical demands of special needs parenting over the years to come.

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Not Making It To the Potty In Time? Three Reasons Why Special Needs Kids Have Accidents

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If your special needs child isn’t experiencing a medical reason for incontinence (infection, blockage, neurological impairment) then you might be facing one of these three common roadblocks to total training success:

  1. Your child has limited or incomplete interoceptive awareness.  What is interoception?  It is the ability to sense and interpret internal cues.  The distention of the bladder, the fullness of the colon, etc are all internal cues that should send them to the potty.  Unfortunately, just as poor proprioception can hinder a child’s ability to move smoothly, poor interception can result in potty accidents, among other things.  Working with them to become more aware of those feelings can include monitoring their intake and elimination routines.  You will know when they should have more sensory input, and can educate them about what that means.  Listen to how they describe internal feelings.  Kids don’t always know the right words, so use their words or give them a new vocabulary to help them communicate.
  2. Your child’s clothing is difficult to manage, or their dressing skills aren’t up to the task.  They run out of time before nature calls.  Tops that are hard to roll up, pants that have tricky fasteners, even fabrics that are hard to grasp and manipulate.  All of these can make it a few seconds too long once they get into the bathroom.  If you are not in there with them, you may have to ask them to do a “dry run” so you can see what is going on and what you can change to make undressing faster.  In my e-book, The Practical Guide To Toilet Training Your Child With Low Muscle Tone, I teach parents the best ways to teach dressing skills and the easiest clothing choices for training and beyond.  If you have ever had to “go” while in a formal gown or a holiday costume, you know how clothing choices can make it a huge challenge to using the toilet!
  3. Your child is too far from the bathroom when they get the “urge”.  Children  with mobility problems or planning problems may not think that they are in trouble right away.  They might be able to get to the bathroom in time in their own home.  When they are out in public or at school, the distance they have to cover can be significant, and barriers such as stairs or elevators can be an issue.  Even kids playing outside in their own yards might not be able to come inside in time.  If you can’t alter where they are, teach them to use the potty before they go outside or when they are near the bathroom, instead of waiting.  Taking the time to empty a half-full bladder is better than an accident.

Looking for more information on toilet training?  Read How To Teach Your Child To Wipe “Back There” and Low Tone and Toilet Training: Learning to Hold It In Long Enough to Make It to The Potty.  and of course, my e-book is available for more extensive assistance The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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Toilet Training For Preschool And Stuck in Neutral? Here’s Why…..

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Many of my clients are in a rush to get their kid trained in the next few weeks for school. They have been making some headway over the summer, but things can stall out half-way through.  Here are some common reasons (but probably not all of them) why kids hit a plateau:

  1. They lose that initial boost of excitement in achieving a “big kid” milestone.  Using the potty isn’t an accomplishment now, it is just a chore.
  2. Parents and caregivers aren’t able to keep up the emotional rewards they need.  It is hard to be as excited about the 10th poop in the potty as the first time.
  3. The rewards used aren’t rewarding anymore.  A sticker or a candy might not be enough to pull someone away from Paw Patrol.
  4. An episode of constipation or any other negative physical experience has them worried.  Even a little bit of difficulty can discourage a toddler.
  5. Too many accidents or not enough of a result when they are really trying can also discourage a child.
  6. Using the potty is now a power play.  Some kids need to feel in control, and foiling a parent’s goal of toileting gives them the feeling that they are the ones running the show.  “I won’t” feels so much better than “I did it” for these kids.
  7. Their clothes are a barrier.  When some families start training, it is in the buff or with just underwear.  Easy to make it to the potty in time.  With clothes on, especially with button-top pants or long shirts, it can be a race to get undressed before things “happen”.
  8. They haven’t been taught the whole process.  “Making” is so much more than eliminating.  Check out How To Teach Your Child To Wipe “Back There” and The Ten Most Common Mistakes Parents Make During Toilet Training for some ideas on how to teach the whole enchilada.  And if you need a great book for kids without developmental or motor delays, look at my review A Great Toilet Training Book for Neurotypical Kids: Oh Crap Potty Training!.

Should you pause training? The answer is not always to take a break.  I know it sounds appealing to both adults and kids, but saying that this isn’t important any longer has a serious downside.  If your child has had some success, you can keep going but change some of your approaches so that they don’t get discouraged or disinterested.  If your child really wasn’t physically or cognitively ready, those are good reasons to regroup.  But most typically-developing kids over 2 are neurologically OK for training.  They may need to develop some other skills to deal with the bumps in the road that come along for just about every child.

Sometimes addressing each one of these issues will move training to the next level quickly!  Take a look at this list and see if you can pick out a few that look like the biggest barriers, and hack away at them today!

For kids with low muscle tone, including kids with ASD and SPD, take a look at my e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone.  Read Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!) to understand why I wrote this book just for you!   

I give parents clear readiness guidelines and tips on everything from the best equipment, the best way to handle fading rewards, to using the potty outside of your home.  It also includes an entire chapter on overcoming these bumps in the road! To learn more about what my e-book can do for you, read The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

Potty Training Boys: Do You Teach Standing Up Or Sitting Down?

 

darran-shen-477150.jpgTraining children for bladder control before bowel control is often easier for quite a few reasons:  More frequent bathroom trips = more opportunities for success, digestion and diet issues don’t stall success,  and urination is usually a painless, phobia-free, and quick experience.  In general, families that hire me as a consultant are encouraged to consider bladder training to be the first mountain to conquer.

But should little boys sit or stand to do the deal?  After a child has been sitting on the potty, understands it’s use, and has consistent success, I will encourage parents to have their sons stand to urinate.  But it isn’t as simple as that.  There are pros and cons.

First, the pros of standing to urinate:

  • little boys have probably seen their brothers, cousins and dad use the toilet, and most children want to copy their same-gender parent.  This is often more motivation to become independent in the bathroom.
  • young children may be a little more mindful of why they are standing in front of the toilet.  Children that are sitting have a harder time seeing what is happening and can get distracted. I know, I know, even the “big boys” can have terrible aim.  But children need all the help they can get to stay focused.
  • improving aim is motivation to use the toilet.  I wrote a blog post on using targets to teach boys to improve their accuracy and build interest in toileting.Piddlers Make Potty Training Fun!  These really work!

And now the cons:

  • See the item about distractibility under “pros”.  Some boys are so distracted that sitting on an toilet seat insert with a splash guard is the only way to prevent spraying the bathroom and any supervising adult.
  • Some children will start out urinating and begin to have a bowel movement concurrently.  Oops!  These children often have issues with low tone or digestive problems, and cannot “hold it” long enough to finish urinating and then sit on the toilet to have a bowel movement.  If they have an accident, it could be very upsetting to them and make them less eager to be fully trained.
  • Children with low muscle tone or postural stability issues may need to sit to achieve a safe and stable position.  No one can eliminate when they are unsteady or fearful.

Some children are vocal and clearly tell you what they want to do and why.  Some cannot or will not communicate, but you can figure out what they are thinking.  Some need to be encouraged to give standing a try.  If your son was initially interested and now has lost some of his enthusiasm and is still sitting to urinate, try telling him that it is time to stand like the big guys and see if you can regain some of your momentum in toilet training!

For more information on toilet training children with low muscle tone, check out my other posts such as  Should You Install a Child-Sized Potty for Your Special Needs Child?and  Low Tone and Toilet Training: The 4 Types of Training Readiness   as well as my useful e-book.  Here is a post that explains why this unique book will help you move forward with training right away! The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

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How To Teach Your Child To Wipe “Back There”

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Potty training is a process.  For most kids, the final frontier is managing bowel movements.  Compared to learning to pee into the toilet, little kids are often more stressed by bowel movements and have less opportunities to practice.  Most children don’t have more than one BM per day, but they urinate many times per day.  For an overview on wiping, even if your child doesn’t have low tone, read Low Tone and Toilet Training: Teaching Toddlers to Wipe

Constipation or just the discomfort of normal bowel elimination can make them wary, sometimes enough to convince some children that this is a process better done in a diaper.  In comparison, urination isn’t an uncomfortable experience for healthy children.  Bowel movements sometimes only happen only a few times a week, instead of the multiple times a child needs to urinate per day.  Less practice and fewer opportunities for rewards (even if your reward is warm praise) make bowel training harder.

So when they finally make the leap and manage to do #2 in the toilet, a lot of parents decide to delay teaching their child how to wipe themselves.  After all, wiping can be messy and it has to be done well enough for good hygiene.

Here are my top suggestions to make “making” a complete success:

  1. Teaching should still be part of your narrative while you are the one doing the wiping.  In my book, The Practical Guide To Toilet Training Your Child With Low Tone, I teach parents how to transform daily diapering into pre-teaching.  While you are wiping, and even while you are waiting for them to finish on the toilet, your positive narrative about learning this skill doesn’t end.  You are telling your child how it’s done, in detail, as you are doing it. You convey with your words, your tone and your body language that this is a learn-able skill.
  2. Don’t forget the power of the “dry run”.  Practice with your child when he is in the bathroom, whether it is before bath time, before dressing, or during a special trip to the bathroom to practice.  Dry runs take away the mess but teach your child’s brain the motor planning needed to lean back, reach back and move that hand in the correct pattern.  The people that invented the Kandoo line of wipes have an amusing way to practice posted on their site:  spread peanut or sunflower butter on a smooth plate, and give your child some wipes or TP.  Tell him to clean the plate completely.  This is a visual and motor experience that teaches how much work it is to clean his tush well.  After this practice, your child will make a real effort, not just wave the paper around.  Brilliant!
  3. Will you have to reward your child for practicing? Possibly.  It doesn’t have to be food or toys.  It could be the ability to choose tonight’s dessert for the family, or reading an extra two books at bedtime.  You decide on the reward based on your values and your child’s desires.
  4. Use good tools.  The adult-sized wet wipe is your friend.  The extra sensory information of a wet wipe versus a wad of dry paper is helpful when vision isn’t an option.  They are less likely to be dropped accidentally when clean, but having a good hold is especially important after it has been used. “Yucky”stuff  makes kids not want to hold on!  Wet wipes are more likely to wipe that little tush cleanly.  Don’t cut corners.  Allow your child to use more than one.
  5. Take turns.  Who wipes first and who bats “clean-up” (couldn’t resist that one!) is your decision.  Some children want you to make sure they are clean before they try, and some are insistent that they go first with anything.  This can change depending on mood and even time of day.  Be flexible, but don’t stand there like a foreman, ordering work but not willing to help out.  One of my favorite strategies is to always offer help, but be rather slow and inefficient.  This gives children the chance to rise to the occasion but still feel like you are always willing to support them.
  6. Teach them how to know when they are done wiping.  It’s kinda simple;  you wipe until the toilet paper is clean when you wipe.  This usually means little kids have to do at least two separate wipes, but they get the idea quicker.  Little hands are not that skilled, but dirty versus clean is something they can grasp.

 

Looking for more information on toilet training?  Take a look at my e-book, The Practical Guide To Toilet Training Your child With Low Muscle Tone to get a clear understanding of how to prepare for and execute your plan without tears on both sides.  Will it help you even if your child doesn’t have low muscle tone?  Of course!  Most of my techniques simply speed up the learning process for typically-developing children.  And who doesn’t want to make potty independence happen faster?

This e-book is available on my website tranquil babies, at Your Therapy Source (a great site for parents and therapists), and on Amazon.  Read more about my book with Amazon’s “look inside” section, or by reading The Practical Guide to Toilet Training Your Child With Low Muscle Tone: Potty Training Help Has Arrived!

The Difference Between Special Needs and Typical Potty Training Approaches: Address Sensory/Behavioral Issues and Use Consistent Routines

tai-jyun-chang-270109.jpgAfter writing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, I have been asked what was different about my book. There must be 100 books on potty training special needs kids. What did I do differently? Simple. I am an occupational therapist, so I have no choice but to use my 360 degree viewpoint to target all the skills needed to do the job. Seeing the path to independence in this way was second nature to me, but not to parents of kids with special needs. Time to offer some support!

The books I reviewed before I started writing were great, but every one lacked at least one important feature. If the authors were psychologists and teachers, they weren’t fully comprehending or directly addressing the sensory and motor aspects of a very physical skill. Oops.

OTs are always aware of the cognitive and social/behavioral components of activities of daily living, but we also have a solid background in physiology and neurology as well. That makes us your go-to folks for skills like toilet training. And that is a major reason why The Practical Guide is so helpful to the frustrated parents of children with SPD,autism, Down Syndrome, Ehlers-Danlos Syndrome, and a host of other diagnoses that result in delays or difficulties with muscle tone and potty training independence. It explains in detail how low tone creates sensory, motor, and social/behavioral problems, and how to address them. Knowledge is power, and knowledge leads to independence.

The other huge difference is that developing consistent sensory-motor-behavioral routines matter more for these kids. Tone isn’t a constant, as anyone with a child that has low tone knows all too well. Fatigue, illness, even a very warm day; these all make kids less stable and can even reduce their safety. Having a really solid routine makes movements easier to execute and more controlled when situations aren’t perfect. Kids with normal muscle tone can shift their behavior on the fly. They can quickly adjust and adapt movement in ways that children with low tone simply cannot. It isn’t a matter of being stubborn or lazy. Kids with low tone aren’t going to get the sensory feedback fast enough to adjust their motor output.

Good motor planning on a “bad day” occurs for these kids when they have well-practiced routines that support safe and smoothly executed movements. What makes the difference isn’t intelligence or attention. It is recalling a super-safe routine effortlessly. This is completely attainable for kids who have speech or cognitive issues as well as issue with low tone and instability. It may take them longer to learn the routine, but it pays them back with fewer accidents and fewer tears.

To learn more about my book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, visit my website, tranquil babies.com, or view it on Amazon.com!ferris-wheeltai-jyun-chang-270109

Teach Kids With Ehlers-Danlos Syndrome Or Low Tone: Don’t Hold It In!

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People who have read my blog are aware that I wrote a book on toilet training, The Practical Guide to Toilet Training Your Child With Low Muscle Tone. The issue of kids who “hold it in” didn’t make it into the book, but perhaps it should have. Children that have problems with muscle tone or connective tissue integrity (or both) risk current and future issues with incontinence and UITs if they overstretch their bladder or bowel too far. We teach little girls to wipe front-to-back to prevent UTIs. We need to teach all children to avoid “holding it in” in the same manner that we discourage them from w-sitting.

I am specifically speaking here about kids with Ehlers Danlos Syndrome, Down Syndrome and all the other conditions that create pelvic weakness and muscle control issues. But even if your child has idiopathic low tone (meaning that there is no identified cause) this can still become a problem.

The effects of low tone and poor tissue integrity on toilet training are legion. Many of them are sensory-based, a situation that gets very little acknowledgment from pediatricians. These children simply don’t feel the pressure of their full bladder or even a full rectum with the same intensity or discomfort that other children experience. This is known as poor interoception, a sensory-based issue that is rarely discussed, even by parents and occupational therapists that are well versed in other sensory processing issues.  For more on how sensory problems affect toilet training, see Why Low Muscle Tone Creates More Toilet Training Struggles for Toddlers (and Parents!).   Kids that don’t accurately perceive fullness can be “camels” sometimes, holding it in with no urge to go, and have to be reminded to void. It can be more convenient for the busy child to keep playing rather than go to the bathroom, or it can save a shy child from the embarrassment of public bathrooms; she prefers to wait until she returns home to “go”.

This is not a good idea at all! The bladder is a muscle that can be overstretched in the same way the hip muscles loosen in children who “W-sit”. Don’t overstretch muscles and then expect them to work well. In addition, the ligaments that support the bladder are subject to the same sensory-based issues that affect other ligaments in the body: once stretched, they don’t bounce back. Holding urine instead of eliminating just stretches vulnerable ligaments out.  A weak pelvic floor is nothing to ignore. Ask older women who have had a few pregnancies how that is working out for them.  Read Is Your Constipated Toddler Also Having Bladder Accidents? Here Are Three Possible Reasons Why to learn why you should be connecting both types of incontinence and taking action sooner rather than later.

For children with connective tissue disorders such as Ehlers-Danlos syndrome, another comorbidity (commonly occurring disorder) is interstitial cystitis (IC).  What does that feel like? The pain of a bad urinary tract infection without any bacterial infection.  Anything that irritates the walls of the bladder adds stress to tissue.  Regular elimination cannot prevent IC, but good bladder care could minimize problems.  Not holding it in is part of good bladder care.

The stretch receptors in both the abdominal wall and in the bladder wall that should be telling a child with low tone that it is time to tinkle just don’t get enough stretch stimulation to do so when they have been extended too far.

When should you teach a child not to hold it in?  Right from the start.  The time to prevent problems is when a child is developing toileting habits, not when problems have developed.  One way to encourage children to use the bathroom is to make it optimally accessible.  Read Should You Install a Child-Sized Potty for Your Special Needs Child? and see if this affordable potty will help your child feel confident and independent right away!

So….an essential part of toileting education for children is when to head to the bathroom. If your child has low muscle tone or a connective tissue disorder that creates less sensory-based information for them, the easiest solution is a routine or a schedule. They use the bathroom whether they feel they need to or not. The older ones can notice how much they are voiding, and that tells them that they really did need to “go”.   The little ones can be rewarded for good listening.

Understanding that the kidneys will fill up a child’s bladder after a large drink in about 35-45 minutes is helpful. But it can always be the right time to hit the bathroom shortly after a meal, before leaving the house, or when returning home. As long as it is routine and relatively frequent, it may not matter how a toileting schedule is created. Just make sure that as they grow up, they are told why this is important. A continent child may not believe that this is preventing accidents, but a child who has a history of embarrassing accidents in public may be your best student.

Many kids with hypermobility have bedwetting issues long after most kids are continent at night.  It helps to explain to them why this may be an issue for them.  Without that discussion, kids often assume that there is something inherently wrong with them as people.  Don’t let your child’s self-esteem drop because they don’t understand why this is such a hard thing to accomplish.  Understanding also makes them more willing to follow a toileting schedule or to focus on developing interoceptive awareness.  If you are wondering if your child’s hypermobility has emotional and behavioral impact, read How Hypermobility Affects Self-Image, Behavior and Regulation in Children and Hypermobility and ADHD? Take Stability, Proprioception, Pain and Fatigue Into Account Before Labeling Behavior .

For little girls who are at a higher risk of UTIs, I tell parents to teach wiping after urination as a “pat-pat” rather than the standard recommendation of front-to-back wiping.  Why?  Because children aren’t really good at remember that awkward movement, and even if you are standing right their reminding her, she may just wipe back-to-front because that is easier and more natural.  “Pat-pat” is an easy movement and reduces her risk of fecal contamination.  I cannot tell you I have done hard research on this strategy reducing infections, but then, I have common sense.  This is the smarter way for her to wipe.  Want more info on wiping?  Check out How To Teach Your Toddler To Wipe “Back There”

Maybe you have the opposite problem; a child who doesn’t know that they need to head to the bathroom until the last moment.  Read For Kids Who Don’t Know They Need to “Go”? Tell Them to Stand Up for a simple strategy to increase sensory awareness and help them connect the dots in time to make it to the potty!

The good news in all of this? Perceiving sensory feedback can be improved. There are higher-tech solutions like biofeedback, but children can also become more aware of bladder fullness without tech.  There are physical therapists that work on pelvic and core control, but some children will also do well with learning how to use Kegels ( contractions of the pelvic floor muscles surrounding the urethra)  and other methods of building awareness of the internal sensations of fullness and urgency.  Many occupational therapists use the Wilbarger Protocol for general proprioceptive awareness.  If your child has Ehlers-Danlos Syndrome, please read Can You Use The Wilbarger Protocol With Kids That Have Ehlers-Danlos Syndrome? for information on how to use this treatment technique wisely.

Looking for more toilet training information?

My e-book, The Practical Guide to Toilet Training Your Child With Low Muscle Tone, has readiness checklists that help you decide what skills to work on right away, and detailed strategies for every stage of training.  I want children to become independent and confident, and for parents to feel good about their role in guiding kids to develop this important life skill.

If you are interested in purchasing The Practical Guide to Toilet Training Your Child With Low Muscle Tone, please visit my website, tranquil babies and click on “e-book” at the top ribbon. You can also buy it on Amazon and your therapy source

Need more than toilet training help?

The JointSmart Child:  Living and Thriving With Hypermobility Volume One:  The Early Years and Volume Two:  The School Years are finally available!  These e-books help parents with all the self-care challenges, helps them figure out the right chairs, bikes, sports and even pencils, and learn the easiest way to teach their child to get dressed and stay safe on the playground.  Both books are packed with strategies that help kids and therapists as well, plus checklists to improve communication within the family, with teachers, and even with a child’s doctors.  Both books are unique resources that empower parents and inform therapists!  Read more about Volume One here: The JointSmart Child Series: Parents of Young Hypermobile Children Can Feel More Empowered and Confident Today! and Volume Two here: Parents and Therapists of Hypermobile School-Age Kids Finally Have a Practical Guidebook!  .

You can find the digital downloads on Amazon.com , and don’t worry if you don’t have a Kindle; Amazon has a simple way to load them onto your iPhone or iPad!  http://yourtherapysource.com also sells them as printable downloads.  They are a great place to find materials if you are a therapist or if you want the latest in information for your child.